Transcript 0504MMAKocotDuran (Long Term Care: Medicare Prescription

Long Term Care: Medicare
Prescription Drug Coverage in
Institutions and Our Communities
Larry Kocot
Vanessa Duran
MMA Requirements regarding Access
to Part D Drugs in LTC Facilities
• Section 1860D-4(b)(1)(C)(iv) of the Act requires
convenient access to Part D drugs for residents
of LTC facilities.
• Sec. 107 of the MMA requires a report to
Congress:
– Assessing the current standards of practice, clinical
services, and other service requirements generally
used for pharmacy services in long-term care settings
– Evaluating the impact of those standards with respect
to patient safety, reduction of medication errors and
quality of care.
Regulatory Access Standards for LTC
Pharmacies (§423.120(a)(5))
• Plans must demonstrate convenient access to
LTC pharmacies
– Offer standard contracting terms & conditions to all I/T/U
pharmacies in service area
– Must contract with “any willing pharmacy”
• Standard terms and conditions must conform
with certain performance and service criteria for
the provision of LTC pharmacy services
established by CMS in further guidance
• CMS has provided separate guidance regarding
how convenient access to LTC pharmacies will
be assessed
Regulatory Network Access Standards for
LTC Pharmacies (§423.120(a)(5))
• Anticipated benefits of our LTC access
policy:
– Plans may negotiate more competitive market
rates with LTC pharmacies
– LTC facilities will likely be able to select just
one LTC pharmacy to serve their residents
– May allow LTC facilities to negotiate more
competitive rates for additional services for
their residents from LTC pharmacies
LTC Guidance: LTC Pharmacy
Performance and Service Criteria
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Comprehensive inventory and inventory capacity
Pharmacy operations and prescription orders
Special packaging
IV medications
Compounding/alternative forms of drug compositions
Pharmacist on-call service
Delivery service
Emergency boxes
Emergency logbooks
Miscellaneous reports, forms, and prescription
ordering supplies
LTC Guidance: Convenient Access
• Convenient access to LTC pharmacies for 2006:
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Work plan
Performance and service criteria
Contracting with any willing pharmacy
Attestation of convenient access and list of network
LTC pharmacies by August 1, 2005
• Convenient access in future contract years may
look at:
– Enrollment/disenrollment rates
– Complaints
– Linking beneficiaries to LTC pharmacies to verify LTC
pharmacy capacity
LTC Guidance: Formulary
• Plans must have a single formulary for all enrollees
• Plans must establish an appropriate transition process
for new enrollees:
– Procedures for medical review of non-formulary drugs
– Procedures for switching enrollees to therapeutically equivalent
alternatives failing affirmative medical necessity determination
– Temporary one-time supply fills recommended
– Documentation of range and circumstances impacting transition
timeframes
– Other transition methods (e.g., contacting enrollees in advance
of initial effective date of enrollment)
LTC Guidance: Exceptions &
Appeals
• We expect plans to consider interrelationship between
LTC facility, LTC pharmacy, attending physician, and
relevant laws and regulations in establishing grievance,
coverage determination, and appeals processes
• Part D sponsors must clearly articulate financial
responsibility of plans when Part D requirements and
Medicare conditions of participation (COPs) conflict
• Recommend that plans consider one-time temporary or
emergency supply process as a stopgap while an
exception or appeal request is in process
• Regulations allow an appointed representative to act on
an individual’s behalf